Primary Care for Low Back Pain: We Don’t Know the Half of It

Author: Frank M. Painter

Evidence-based medicine helps health care professionals and patients decide best care, drawing on research about effectiveness and safety of interventions. Systematic reviews summarise the evidence; guidelines report consensus between experts (including patients) on interpreting it for everyday practice. Although guideline recommendations are only one component of shared decisions that will vary patient-to-patient, the hoped-for outcome is health benefit for each individual. Guidelines also inform starker decisions by policymakers and health care leaders — for example, when to withdraw approval or funding for a poorly evidenced or harmful intervention. To assess whether all this research-driven activity is useful, 2 questions need answering: how well are guidelines followed in real-life practice and do patients benefit in the long-term?

In a new systematic review, Kamper et al. tackle the first question in relation to first-contact care for patients with low back pain provided by family practice and emergency department physicians. As the authors state, low back pain has major significance for the international pain community. It is the leading single cause of years lost to disability globally, and there is good evidence for what constitutes best first-contact treatment. The review selected best-quality studies of routine health care data to investigate whether first-contact physicians are putting back pain guidelines into practice (“usual care”). The results paint a bleak picture: only a minority of patients apparently receive simple positive messages to stay active and exercise, while inappropriate use of analgesia and imaging persists. The review adds to evidence that the care doctors give patients with low back pain is dominated by guideline-discordant interventions that are unnecessary, expensive, and “low-value” (ie, harm is more likely than benefit).

These findings are not entirely unexpected nor, as the authors point out, should blame be placed entirely at the door of front-line physicians. Qualitative studies reveal family practitioners agreeing with guideline conclusions but frustrated in implementing them by factors such as patients with complex needs or lack of resources for behavioural interventions and rehabilitation.

Furthermore, physicians will point to the nuances of individual patients who do not neatly fit the template for guideline recommendations. The review’s authors acknowledge this when discussing the difficulty of measuring “appropriateness” of physician requests for imaging.

The review did not study nonphysician primary care providers. Many such practitioners deliver care aligned with guidelines, such as advice about activity and exercise. More allocation of first-contact low back pain care to professionals such as physical therapists [AND chiropractors] could help to address the problem of inappropriate care. However, although some back care, such as imaging requests by physical therapists, may be more guideline-concordant, a recent systematic review indicated physical therapists have low adherence generally to guidelines for musculoskeletal pain, and a comparison of nurse practitioners and physicians in primary care revealed similar rates of unnecessary imaging requests.

It is increasingly clear that simply expecting individual clinicians to adhere more closely to guidelines is not going to close the evidence-practice gap. Recent articles have argued that effective “high-value” care for patients with low back pain (“benefit more likely than harm”) will only be achieved through large-scale top-down changes across health and social systems (“system strengthening”).

Such changes include engaging policymakers, politicians, and profession leaders to change laws and reimbursement practices; addressing counterproductive commercial pressures; creating incentives for optimal care; providing adequate resources for delivery of guideline care (including digital innovation); shifting professional education and training toward high-value care, including nonpharmacological approaches; dissolving boundaries between health care professions to create unified programmes of care; and changing culture and pain literacy among patients and populations to encourage prevention and positive health activity. The success of such innovations, however, cannot be taken for granted and will need evidence that they bring long-term patient benefit.

There is a second important issue highlighted by the authors of the review — the scarcity of relevant information to answer their question “how well are back pain guidelines implemented?” The review focused on studies reporting actual clinical care because it was recorded in health care or insurance databases. A challenge for data collection systems, particularly in family practice and emergency departments, is how to ensure such records include all aspects of care. Prescription medicines, imaging requests, and referrals to other services tend to be routinely recorded, whereas the nature and detail of patient assessment, and the content of advice and information given, often go unrecorded. Absence of data may mean either care has not been delivered — or it has been delivered but not recorded. Thirty years after randomised controlled trials reassured patients that an average low back pain episode did not require a week in bed, there is no high-quality data on what primary care physicians have been advising about bed rest.

This absence of information about relevant areas of the primary care consultation should concern us as much as the size of the evidence-practice gap or how to close it. Having the right information will itself help change policy and training and behaviour about guideline treatments, for example, by easing the path to audit as a means to improve practice. The “finely grained” information the review calls for (such as linking prescription records with the indications for prescribing) would address concerns that health care databases do not currently convey all the nuances of decision-making — not all imaging requests are wrong, not all opioid prescriptions are wrong-headed.

The authors of the review could find no high-quality studies using actual practice data from first-contact low back pain care in low- and middle-income countries (LMICs). This is of particular concern because LMIC populations are being exposed to technology and treatments for low back pain (such as opioids) that high-income countries have popularised and made profitable but that are often inappropriate and harmful. Low- and middle-income countries need appropriately strong systems to support delivery of high-value care, including guideline-concordant approaches to low back pain prevention and care that align with local practices and cultures of health and wellbeing. Achieving data collection systems and routine analysis to document low back care is a plausible investment target for LMIC populations such as Nepal that are digitally equipped even when geographically remote11 but will be hindered while pain research has no priority and remains focused on low-value items of care.

It is a strange situation to contemplate. In an information-dominated world where people’s purchasing actions are instantly known, retrievable, linked to other data, and acted upon, the [medical or “usual”] care that most people are receiving for the world’s leading cause of long-term disability is not known because it is either not recorded or the data are not accessible or reported. The challenge to digital science and modern informatics is how to record and retrieve this information without overloading already busy clinicians or saturating patients with data collection. But, along with the challenges and the risks, there is the potential for new technology to change and improve delivery of health care globally for conditions such as back pain.

The case revealed by Kamper et al. for having more accessible, better organised, well-resourced, easily collectable information about the daily content and outcomes of consultations for this most common of disabling pain conditions is clear. The international pain community, in collaboration with health care data scientists, should get behind it.

Antioxidant Dietary Supplement

Aging? Sure, it’s a fact of life. But what if there was a way to slow down the process, perhaps even cure it, what would you say?

The aging process brings with it not only wrinkly skin or tired joints and muscles. Those can be tolerated. After all, they are part of the natural cycle of life. But what isn’t natural is the disease. They are disorders – unnatural conditions of the body.

Aging is caused by harmful molecules called “free radicals.” This was according to Denham Harman, M.D., Ph.D., who first proposed the theory in the 1950s. Since then, scientists and researchers have sought to understand the body’s oxidation process and free radicals contribute to its acceleration. It seemed that these so-called free radicals are rogue oxygen molecules that are highly unstable and which have harmful effects on the body.

There is growing evidence that the production of reactive oxygen species (ROS), including free radicals, is behind the aging process and initiation of age-related disease. The reason free radicals are highly unstable is that they have an unpaired electron which they try to recompense by stealing an electron from a stable molecule. This actually sets off a chain reaction that can damage the body’s proteins and cell membranes, weaken the cell’s natural defenses, and disrupt the cell’s DNA. Such damage, when accumulated, could lead to degenerative conditions.

Fortunately, nature has provided us with a system to help control free radicals. Antioxidants are natural enemies of free radicals because one of their functions is to break the chain reaction and destroy free radicals.

Therefore, while antioxidants can be found in many fresh fruits and vegetables, it still pays to take an antioxidant dietary supplement along with your food. Vitamin C antioxidant dietary supplement is perhaps the most famous form of antioxidant available. Also known as ascorbic acid, bottles of this antioxidant dietary supplement can be found in any pharmacy or health food store. Research shows that this particular form of antioxidant dietary supplement greatly helps in boosting the immune system and thus aid in preventing the onset of degenerative diseases.

Another popular form of antioxidant dietary supplement is Vitamin E. This antioxidant dietary supplement works best when taken with Vitamin C as it seems that both vitamins have a synergistic effect when taken in combination.

Besides vitamins, antioxidant dietary supplements may be in the form of botanicals. Green tea, for example, is a rich source of flavonoid derivatives (polyphenols) epicatechin (EC), epigallocatechin (EGC), epicatechin gallate (ECG), and epigallocatechin gallate (EGCG). All these contribute to what makes green tea a good antioxidant dietary supplement.

Beauty and Fitness

Health is wealth. By being physically fit, it can make a person look lean both inside and out.

There is a lot a person can do such jogging or walking in the morning, playing basketball or any other sport with friends but if a person wants to have muscles and look lean, the best thing to do will be to sign up and workout in a gym.

Just like taking any medicine, one should first consult the doctor before undergoing any form of exercise.

Physical exercise is beneficial because it helps maintain and improve ones health from a variety of diseases and premature death. It also makes a person feel happier and increases ones self esteem preventing one from falling into depression or anxiety. It has also shown to make a person with an active lifestyle live longer than a person who doesn’t.

The best exercise plan should have cardiovascular and weight training exercises. This helps burn calories and increase the muscle to fat ratio that will increase ones metabolism and make one either gain or lose weight.

A person who has never worked out before should do it gradually. Doing it too much for the first time can make one pull a muscle or have an injury making it worse. Endurance will never be built in a day and doing it repeatedly will surely be good to the person.

Focusing on certain portion in the body can help make it improve. A good example is going to the gym and doing a workout more often in a specific area such as the abs can give one a chest pack.

But beauty is not only about having muscles which is what people can see. It is also about enhancing the beauty within.

Here are some things one can do everyday to stay beautiful and healthy;

· Reading books and other reading material more often keeps the mind sharp just like working out keeps the body in shape.

· Work no matter what kind it is produces stress. One can reduce this by taking the time out to do something special like lying in a hot tub, shopping or watching a movie. Studies have shown it is reliever and helps one from looking haggardly.

· Pollution is something people cannot control given the size of the problem. When one goes out, it is best to put some form of protection such as beauty products that contain antioxidants that protect the skin from damage. There are also other beauty products available and choosing the right one with the help of a dermatologist can help the person.

· Another way to stay healthy is to give up some vices. Most people smoke and drink. Smoking has been proven to cause lung cancer and other diseases as well complications for women giving birth. Excessive drinking has also shown to do the same.

· For people who don’t smoke, it is best to stay away from people who do since studies have shown that nonsmokers are also at risk of developing cancer due to secondary smoke inhalation.

· Lastly, it is best to always start the day with a positive outlook. Just as studies have shown that exercise makes a person feel happier, smiling produces the same effect. A smile can do a lot and it is contagious in a positive sense. It brightens the day of not only one but others as well.

What Can I Expect from My Acupuncture Treatment?

Although it is been done for thousands of years in Asia, some people are still very nervous about going to an acupuncturist for treatment. As the practice becomes more accepted, however, and the use of acupuncture is becoming more prevalent, many individuals will find themselves getting this treatment for the first time. If you are a little bit nervous about your acupuncture treatment, you are in good company but that doesn’t mean that you have a need for alarm. Here is what you can expect from your visit to the acupuncturist.

The first visit will actually be a question-and-answer session and may or may not include acupuncture at all. Your doctor will want to know almost everything about your medical condition, and the underlying issues and anything else that may help him in his treatment of your condition. Once the proper treatment is discerned, however, your treatments will start, perhaps even on the first visit.

This is where most people get nervous because they are unsure about the dangers that may exist from acupuncture. Let me put your mind at ease. It is very rare for there to be any problems from acupuncture treatment and, as long as you’re acupuncturist is using clean needles and knows what they are doing, you have little to worry about at all. It is possible for infection to set in or for an organ to be punctured but this is very rare if you’re acupuncturist is qualified.

Each session will last about one half hour and your doctor will insert very tiny needles into the acupuncture points and may manipulate them somewhat with his hands, induce a very light electrical pulse or even warm them with moxa. The needles will remain in your body for anywhere from five to 20 minutes. Most people do not feel any discomfort at all from having these needles inserted and actually may feel invigorated in some cases or perhaps very relaxed.

After your first time of receiving acupuncture, you will find that it is not an unpleasant situation at all. As a matter of fact, you may leave the acupuncturist feeling very good, relaxed and with an overall sense of well-being. In fact, once you begin with your acupuncture treatments you will probably wonder why you waited so long to begin them in the first place. It’s an ancient medical practice but it can still take care of many things for us today.

Commit To Be Happy

Today, why not made a personal commitment to be happy, in spite of what life hands over to you. You have to admit that there are too many things over which you have no control. The only thing you can do is to stop allowing them to make dents in your spirit.

Happiness is not something that others can take from you. It’s something that you would have to throw away on your own.

There will be times when things don’t turn out the way you want them to. Your best friend at work may turn out to be a power-hungry corporate animal that backstabs you at every opportunity. The promotion you worked so hard for may go to someone else. Your partner might decide to leave me, a day before we are due to go for a vacation together. You may lose most of your savings in a market crash.

These are things that can happen to the most loving, compassionate, careful and reasonable person. But after the initial pain and shock, the decision whether or not to let yourself languish in despair is entirely up to you. You can allow misfortune to form the bulk of your life, or you can choose to leave what’s past in the past, and move on.

One’s friendly and caring behavior towards others should not be motivated by the thought of equally kind and affectionate responses. You understand yourself best, and regardless of how reasonably and responsibly you live your life, there will be people who won’t see your point of view or share your motivations.

People have the right to act in any way they see fit. I don’t have the right to judge whether their behavior is acceptable or not. They have to bear the responsibility for their own actions, and so do you. By feeling sorry for yourself, you are simply continuing the work for them, long after they have dealt their blow. You have to decide that, as far as possible, you will not allow these people to disturb your mind.

There are many things for which you can be grateful. There are yet unexplored experiences in which you can find enrichment and meaning. There are yet others who will like you for who you are, and in spite of who you are. If you spend my time being resentful and miserable, you are denying yourself the satisfaction of enjoying what this life has to offer.

There are enough unhappy people in this world who punish themselves and others constantly in a bid to find redress and compensation. But there is no satisfaction in retaliation and revenge. It’s a waste of time and spirit.

“To be happy we must not be too concerned with others.”

Albert Camus

The Importance of Healthy Eating

Have you ever heard the saying you are what you eat? In some sense, this is true, because if you eat unhealthy foods you are prone to be an unhealthy person. The foods we ingest are extremely important to our ability to grow, maintain function, and prevent illness. Therefore, if you value your health, you should learn as much about healthy eating as possible.

Healthy eating is important from the day we are born. As a child, we grow quite rapidly and this is due in part to the foods we eat. Foods all contain nutrients that provide us not only with fuel to live our daily lives, but also with the very substances that build our bones, muscles, and organ tissues. Not getting enough of one nutrient or another can cause a variety of problems, including stunting our growth. For mothers who are nursing, nutrition is important because breast milk contains the nutrients a child needs to grow and develop properly. Upon growing older, these nutrients are then found in food, but don’t think that healthy eating isn’t important for growth after you’ve gone through puberty. Cells continuous break down and rebuild, so healthy eating for growth continues to be important until the day we die.

Maintaining function is also not important without healthy eating. In out daily lives, we use energy to think, walk, talk, breathe, and perform any other action. The energy it takes our body to do these things comes from two places: fat reserves in the body or our daily food intake. If you don’t eat healthy foods, you will find that you are storing more fat that necessary or that you aren’t getting enough and you feel sluggish or weak. Along with energy-providing nutrients, like fats and carbohydrates, we also need the right nutrients to allow our organs to do their jobs. Hormones and other substances in the body make sure that everything is working properly. If you don’t eat the right nutrients, your body cannot produce these hormones and, as a result, cannot function properly.

Lastly, healthy eating is important in order to prevent illness. When we do not get the right nutrients, or body’s natural defense system against diseases weakens, allowing viruses and bacteria to attack the body. It’s like a well-trained army—if the army doesn’t have enough to eat, it will not do well in battle. Without healthy foods and plenty of water, our bodies simply could not operate on a day-to-day basis. Learning how to eat healthy foods is therefore and important lesson, and one which we should begin learning as children.

Breathing, Exercise and Eating

If I had not gone through several diet and exercise programs, I would not believe the connection that the elements of breathing, exercise and eating share. Since I have however, received quite and education in these three areas, I can vouch for the certain fact that they are all interrelated and do affect the body individually and jointly.

Now, the eating and exercise you may have already figured out, but are you aware of the role our breathing plays in providing the body with the oxygen needed for maximum metabolism? No, most people aren’t.

This is how the process works. In order to metabolize food, the body needs certain elements to come together and create the right conditions for food breakdown. Oxygen is one of the elements. The more oxygen we add to the process, the better our metabolic process can work to properly utilize the energy from the food we have consumed.

It is here that our breathing plays a key role in the metabolic process. The deeper, and more efficiently we breathe, the more oxygen we consume. The more oxygen we consume, the more we provide to the metabolic process. Makes sense doesn’t it?

What role does exercise play in this process? Well, exercise conditions our body to keep it in optimal shape. To keep muscles functioning correctly and build muscle mass. The more muscle we have, the more calories we burn; the more calories we burn, the better our metabolism is at using up the calories we take in through food consumption.

Can you begin to see how our body is really a well functioning machine? It’s a continual circle of events, one feeding off the other. When all the events are coming together properly, we are healthy, happy individuals. It’s only when abuse of the system begins to occur, that we put our bodies in jeopardy. Perhaps is we educated our children, while they are young, about the dangers of abusing their body, we would have better equipped young adults. We educate them about the dangers of household appliances that are incorrectly operated, about the danger of driving recklessly, and improper operation of the car they’re driving; we just don’t take the time to educate them about the most important piece of equipment they will ever operate, their own body.

Exercise, breathing properly and healthy eating are the ingredients vital to the proper operation of the body. Of all the things we ever learn, of all the thoughts we ever entertain, or the abilities we acquire as we grow, our health and the means to maintain it, are the most important. Nothing else works unless our mind and body have been kept in working condition. Have you ever noticed someone who is paralyzed? So many of the choices they could make about how to spend their time, playing sports, skiing, or swimming, have been taken away. The same is true for someone who has abused their body to the point of being an invalid; so many of the choices that could have been made
to enrich their lives, have been taken away.

Nature: The Great Stress-Reliever

You might feel as if your senses are constantly being bombarded, both at work and at home. As a result, stress might have led you to the breaking point.

But there is a great universal stress reliever—one that is close to everyone. Nature offers bountiful opportunities for relieving stress. It might seem old-fashioned to “commune with nature,” but it can be incredibly cathartic, decreasing your stress level immeasurably.

First, you must be willing to take the time to drink in nature and all its beauty. Often, we feel overwhelmed by commitments—so overwhelmed, in fact, that we become guilty if we take time out for ourselves. However, if we are to successfully combat stress, we absolutely must reserve time for stress-relief, and nature can be one of the best stress relievers available.

Each season offers its own unique brand of stress relief. In the autumn, we can be soothed by the multi-colored leaves on the trees, the crunch of leaves under our feet, and lovely azure October skies. By experiencing the beauty of nature, we can become more relaxed and better able to take on life’s challenges.

In the winter, we can take brisk walks through the snow, watching the flakes delicately float down to earth. We can be energized by the brisk winds and frigid temperatures. We can also gain a certain amount of confidence in battling the elements, helping to relieve our stress level.

In spring, we can enjoy the true riches of nature. We can experience the scent of flowers just beginning to bloom…the loveliness of plants that have survived winter’s scourge…and listen to the birds chirping in the trees. Gazing at trees just beginning to bud can be incredibly soothing after a stressful day on the job.

Meanwhile, in the summer, we can experience nature at its most vibrant. We can enjoy the scent of the grass after the lawn has just been mowed…and watch the trees gently waving in the summer breeze. We can revel in the sun’s rays, or enjoy the refreshment of a summer shower. Just a few minutes in the outdoors can reduce our stress level dramatically.

There are also a number of nature-related activities we can engage in in order to relax. For instance, hiking offers a tremendous opportunity to see the splendor of nature up close and personal. Skiing allows us to enjoy winter’s beauty, while a game of Frisbee can be a tremendous lift on a summer afternoon. Because nature offers such a feast for the senses, enjoying the outdoors can bring a sense of calm and tranquility to our lives that few other things can.

Some people have found a relaxing nature-related hobby in gardening. Planting flowers, trimming bushes, and weeding can help to relax both the mind and the body. Others have found that yard work can help to reduce stress. Such activities as mowing the lawn, raking leaves, or shoveling snow can help to remove us from sources of stress, giving us a much-needed break.

You may be so inspired by nature that you write poetry about the things you see and hear. Such writing can be tremendously cathartic, especially when undertaken outdoors. Lying in a chaise lounge under a tree, composing sonnets about flowers, can get your creative juices flowing—and lower your stress level in the process.

You might be surprised how therapeutic nature can be. It can re-awaken your senses, allowing you to see things you might have missed before. It can demonstrate to you the beauty of creation and give you a renewed vitality for life. It can provide you with a welcome sanctuary from the world of blaring stereos and non-stop TV chatter. Even if you don’t consider yourself a nature lover, brief periods outdoors can give you a new sense of purpose. With such a positive outlook, your ability to handle stress will be enhanced. In essence, spending a few moments outdoors is like taking a mini-vacation from the rigors of your daily life.

The Benefits of Yoga

Yoga, as you may know, is practiced by millions of people throughout the world for several good reasons. It has been around for thousands of years now and it is continually gaining popularity for a number of benefits that it is capable of giving.

Well, speaking of benefits, one may find the benefits of yoga countless. There are too many of them to mention, but all are tailored to one particular purpose – to maintain better health and well-being through the unity of the mind and body. The benefits of yoga can be classified into three categories according to where they may occur: physical, mental and spiritual.

Physical Benefits of Yoga

Yoga is in the first place a philosophy composed of exercises that is highly capable of making the physical body as healthy as possible. Several claims have it that the exercises involved in the practice can help increase the muscle strength of a person. It strengthens the muscles and joints in the back and abdominal muscles, which are but two of the most vital elements of the spine’s muscular network which works to help the person obtain a proper posture.

The yoga can also aid relaxation. It is said to alleviate pains and stress not only in the muscles, but in the entire body. This benefit is made possible by the yoga movements that involve stretching, as well as for the breathing exercises which are done throughout the practice.

Most of all, the practice of yoga will make you aware that your body has its own limitations. Knowing this fact will help you prevent all sorts of injuries and bodily imperfections knowing that you already know what and what not to do.

Mental Benefits of Yoga

It is believed that if you are doing the yoga techniques regularly, there is a great possibility that you will be relaxed to the highest possible level. You can also handle certain situations that are stressful more easily. And, most of all, you will know exactly how to encourage yourself to think about positive thoughts. Recent researches have further revealed that the mental benefits of yoga may also include self-acceptance.

Spiritual Benefits of Yoga

In terms of spiritual benefits, yoga is deemed to be so potent for making you aware of everything about your body, as well as your emotions and the feelings of others. Many of the expert yogis even claim that practicing the yoga exercises will help promote a sense of interdependence that may involve not only the body, but also the mind and spirit. This is actually where the idea of “oneness” comes in.

20 Minute Home Work Out

Self quarantine home work-out.

1) Jog : in one place for 3 minutes

2) Jumping Jacks : 25 repeats
When landing, bend your knees slightly to reduce the impact on knee joints.

3) Crunches : 15 repeats
Lie flat on your back with your knees bent. Place your hands behind your head with elbows pointing outwards. Support your neck with your hands. Keep your neck in a straight line with your spine. Flex your waist to raise the upper torso from the mat. Lower yourself until the back of your shoulders touches the mat.
Muscle worked: rectus abdominis

4) Hip Bridges : 10 repeats
Lie on your back. With your hands at a 90 degree angle to the floor, lift your body off the floor to form a straight line, a sort of a bridge, from the shoulders to the knee. The position should resemble a table … your hands and legs as the legs of the table and your upper body to your knees as the surface. Hold this position for two seconds. Squeeze your gluteus (butt muscles) and then lower yourself.
Muscle worked: Lower back, hamstrings and gluteus.

5) Step – Up’s : 1 minute
You will need a stepper for this.
Muscle worked: hamstrings, gluteus, quards.

6) Reverse Crunches: 15 repeats
Lie on your back with your hands on your sides. Keep you knees bent. Bring your knees towards your head, till your hips come slightly off the floor. Hold this position for a second, and then lower your knees.
Muscle worked: lower abs and obliques.

7) Mountain Climbers : 1 minute
Get your hands and knees and raise your knees like a starting block sprinter. Run in that position, supporting your upper body with the palms of your hands. Keep your back straight.
Muscle worked: triceps, deltoid muscle, gluteus, quards, hamstrings, calves.

8) Push – Ups : 15 repeats
Muscle worked: triceps, deltoids, pectorals.

9) Squat Thrusts: 1 minute
Stand straight. Now, drop to a crouch position. Immediately thrust your legs out straight behind on your toes, in push up position, now jump to pull legs back to the chest, in crouching position , then stand up straight,
Muscle worked: arms, legs, chest, and lower back.

Cool down by walking around, till your heart rate starts getting back to normal, stretch.

A minutes rest is needed in between exercise. Proper form is important. Do not hold breath. Sip water during the workout. This workout targets the whole body, improves cardiovascular efficiency and tones and strengthens the body.